The American College of Emergency Physicians polled more than 1,800 emergency room doctors last month, and 46 percent reported increases in patients coming through their doors since Jan. 1, the day coverage took effect for millions under Obamacare. Twenty-seven percent said the number hadn't changed and 23 percent had seen a decline since Jan. 1. Over the next three years, 86 percent of these doctors believe emergency room use will increase.

The survey findings underscore the challenges beyond extending health coverage to more people, including improving access to primary care and changing the habits of patients accustomed to using the emergency room as a one-stop-shop for medical care. One of Obamacare's selling points was its potential to reduce costly emergency room visits for care that could more efficiently be delivered in a doctor's office or other setting, especially for patients who previously were uninsured. Increases in ER visits may provide critics fodder to contend the law isn't fulfilling that promise.

"Coverage does not equal access," said Rebecca Parker, an emergency room doctor in Chicago who is on the board of directors at the Irving, Texas-based American College of Emergency Physicians. "Just because you gave somebody Medicaid doesn't mean that there's a place for them to go in terms of a primary care, outpatient facility," she said.

Patients with and without health insurance seek care from hospital emergency departments for a variety of reasons, including knowledge that hospitals offer a wider array of services than a doctor's office.

A federal law dating to 1986 forbids hospitals from turning patients away from emergency rooms regardless of their ability to pay, which attracts individuals who lack the means to afford medical care elsewhere. In addition, emergency departments lure patients who don't have access to a nearby doctor, or when physician offices are closed at night and on weekends. And patients don't have the medical expertise to tell whether symptoms like chest pains mean they're having a heart attack or indigestion.

Most of the patients who visit the emergency room actually should be there, or at least can't be blamed for going to a hospital when experiencing pain or illness that might be serious, Parker said. "The majority of folks do belong in a kind of acute care setting, which is what we provide," she said. Based on her observations, an increase in emergency department visits could be explained by newly covered patients seeking medical care they postponed while uninsured and choosing a provider they know will treat them, Parker said.

While a survey of emergency department physicians' impressions lacks hard data about patient behavior and can't be considered conclusive, the results are consistent with studies about the effects of Massachusetts' 2007 health care reform law and a 2008 expansion of Medicaid in Oregon. Trevor Fetter, CEO of the for-profit hospital chain Tenet Healthcare, told CNBC this month that his company's facilities also are seeing an uptick in emergency room visits.

Another recent survey, however, reports the opposite is occurring in Arkansas this year. Forty-two hospitals in the state told a legislative committee that emergency department visits are down 2 percent so far this year, and that the number of emergency room visits by uninsured patients fell by 24 percent.

Likewise, nearly a quarter of the doctors who responded to the American College of Emergency Physicians survey observed fewer visits to their facilities, and more than one-quarter report no change, Parker said. Emergency departments seeing a smaller number of patients may be those doing a better job educating individuals about the availability of non-emergency care at other settings, such as urgent care clinics, she said.

The information released by American College of Emergency Physicians is the latest indicator of how the Affordable Care Act's coverage expansion is affecting patients and the health care industry.

Gallup and other organizations have reported reductions in the uninsured rate, although the extent of the decline greatly varies in those surveys and estimates. The Department of Commerce Bureau of Economic Analysis issued a preliminary finding last month that national health care spending has been growing more quickly since late 2013, apparently spurred by more people having health coverage and by consumers who had postponed medical care during and after the Great Recession. A Harvard University study published this month concluded the Massachusetts health reform law saved lives by covering the uninsured also sparked debate about the cost of expanding coverage.

Fewer people died in Massachusetts after the state enacted its landmark legislation to cover the uninsured, according to a new Harvard University study that could have implications for the effects of Obamacare.

A Harvard team compared the mortality rates in Massachusetts before and after then-Gov. Mitt Romney (R) signed the health care reform bill into law in 2006 with the mortality rates in similar counties in other states during the same time periods. Based on their calculations, the mortality rate declined 2.9 percent overall among adults 20 to 64 years old after the law went into effect -- which translates into 8.2 fewer deaths per 100,000 people. So-called Romneycare served as a model for President Barack Obama's Affordable Care Act.

The analysis, which was published by the Annals of Internal Medicine Monday, is the latest attempt by researchers to prove the seemingly obvious relationship between health coverage and the access to medical care it brings with improved health and longer lives. In spite of this intuitive connection, previous research has produced inconclusive results and inflamed scientific and political controversy about whether being uninsured consigns people to poorer health and shorter lives.

Researchers led by physician and economist Benjamin Sommers of the Harvard School of Public Health didn't attempt to provide a definitive answer to these larger questions. However, they did conclude that the lower mortality rate they observed appears to be real, even if its national implications are uncertain amid the reduction in the number of uninsured people seemingly brought about by Obamacare.

"We find a significant reduction in mortality among nonelderly adults in Massachusetts since its 2006 reform relative to a control group of similar counties in states without such reforms. Although this analysis cannot demonstrate causality, the results offer suggestive evi￼dence that the Affordable Care Act -- modeled after the Massachusetts law -- may impact not only coverage and access but also mortality," the report says.

"The extent to which our results generalize to the United States as a whole is therefore unclear, which underscores the need to monitor closely the Affordable Care Act’s effect on coverage, access, and population health across all states," Sommers and his co-authors wrote.

The researchers emphasized that their findings cannot prove that expanding health insurance coverage led directly to lower mortality, and noted that they did not have access to information about specific, individual cases. Researchers used data in Massachusetts and elsewhere in the county from the federal Centers for Disease Control and Prevention and the U.S. Census Bureau to create their comparisons.

The effects of expanding coverage in Massachusetts appear more significant when narrowed down to health problems that can be treated or prevented when individuals have access to medical services. The researchers found the mortality rate for people with these "causes amenable to health care" -- including issues like cancer, infections and cardiovascular disease -- decreased by 4.5 percent in Massachusetts after Romneycare when compared to counties with similar populations. And the connection between expanded coverage was even stronger among people who live in counties with lower income and higher rates of uninsurance, the report says.

If the results of the Harvard analysis are correct and can be applied nationwide, the impact of Obamacare would be significant. According to the Congressional Budget Office, the Affordable Care Act will reduce the number of uninsured people by 12 million this year and by 26 million as of 2017.

Past research attempting to measure the effect of health coverage on health and mortality has produced mixed results. In 2002, the prestigious Institute of Medicine issued research concluding that 18,000 people died in 2000 because they had no health insurance. Six years later, an attorney at the Urban Institute, Stan Dorn, duplicated the IoM study with new data and reported that 22,000 people die each year because they have no health insurance.

But in 2009, political scientist Richard Kronick, a former adviser to President Bill Clinton's administration who was then employed by the University of California at San Diego, reexamined the Institute of Medicine research. Kronick determined that when underlying health factors of the population were considered, no connection could be proven between health coverage and lower mortality. Kronick currently serves in the Obama administration as director of the Agency for Healthcare Research and Quality.

Results of the Oregon Health Study, a major project attempting to measure the effects of health coverage among individuals who won a lottery to sign up for Medicaid in the Beaver State, have also fueled debate about whether providing insurance benefits improves health and prolongs lives. In 2012, researchers revealed that new Medicaid enrollees reported they were in better health than those who lost the Medicaid lottery. But last year, another Oregon Health Study publication didn't find significant improvements in blood pressure and cholesterol among these Medicaid beneficiaries compared to those who couldn't join the program, although those on Medicaid showed improved mental health.

Harvard's Sommers, the author of the new study looking at Massachusetts, serves as an adviser to the U.S. Department of Health and Human Services. The report states that the study's conclusions do not represent the views of the Cabinet agency, and Sommers and his colleagues received no outside funding for their work.

Over 8 million individuals signed up for health insurance via the Obamacare exchanges through April 19, according to an official report from the Department of Health and Human Services that confirms an announcement made by President Barack Obama last month.

During the six-plus months of the first open enrollment period for these marketplaces created by the Affordable Care Act, 8.02 million people chose a health plan. Sign-ups surged during March and April, when 3.8 million signed up for private coverage through the exchanges, according to the department's report. That total represents 47 percent of all enrollments. Eighty-five percent of those customers received financial assistance, the report said.

This chart shows the increase in sign-ups via the marketplaces. FFM stands for the federally facilitated marketplace, and SBM are state-based marketplaces.

"Because of the Affordable Care Act, more than 8 million Americans now have the peace of mind of knowing their coverage can't be taken away if they get sick and won't run out just when they need it the most," Health and Human Services Secretary Kathleen Sebelius said during a conference call with reporters Thursday.

The March and April surge also boosted the share of health insurance exchange customers under the age of 35, a critical metric for the stability of the new state-based markets. Younger customers are considered less costly to insure, so a significant share of these customers -- who tend to use fewer health care services -- is a key counterweight to the costs of covering older, sicker customers.

By the end of the sign-up period, 28 percent of enrollees were aged 18 to 34, and 34 percent were under 35, including children. This share fell short of the White House's goal of 39 percent young adults, but the Health and Human Services report shows that 1.1 million younger consumers flooded the exchanges near the nominal March 31 deadline, doubling their participation in the exchanges from the first five months of sign-ups.

Although enrollments of young adults came in below the Obama administration's target, the prices on the health insurance exchanges shouldn't be markedly higher next year, Michael Hash, director of the HHS Office of Health Reform, said on the press call.

"We believe, based on the data that we've seen and independent data that is out there, that premiums will be stable and that the risk pool is sufficiently large and varied to support that kind of pricing in every state," he said. Mechanisms built into the Affordable Care Act to compensate insurance companies with sicker-than-average customers will help keep prices from spiking, he said.

HHS did not provide information on how many of the 8 million enrollees have paid their first month's premium and actually activated their health insurance coverage. It won't have that information until later this year, Julie Bataille, a spokeswoman for the Centers for Medicare and Medicaid Services, said during the conference call. The HHS report cites anecdotal accounts from major insurers that have reported 80 percent to 90 percent of customers paid up. Those disclosures are at odds with a House Republican report published Wednesday claiming only 67 percent of enrollees from the federal exchanges had paid by April 15, though that date precedes when bills are due for most of the final weeks' sign-ups.

Likewise, the department did not offer data to indicate what proportion of the 8 million private plan enrollees were previously uninsured, but it noted outside analyses from the Congressional Budget Office and others indicating millions have gained coverage since last year. The HHS report said that 87 percent of the 5.2 million exchange users who applied for financial assistance reported being uninsured before, but officials on the conference call stressed that figure is subject to significant uncertainty.

The national enrollment figures will shift over the remainder of the year for a variety of reasons. Individuals who never pay a premium or allow their coverage to lapse later will reduce the total. The HHS report also doesn't include enrollments still being processed from states that extended the final deadlines further, including Hawaii, Oregon and the District of Columbia, which were still accepting customers through Wednesday. And individuals who experience a "qualifying life event" during the year, such as getting married or moving to a new state, can access the exchanges before the next enrollment period, which begins Nov. 15.

The federal government's report also doesn't include any of the millions of people who purchased an Obamacare-compliant health insurance policy directly from an insurer or broker. Even though these so-called off-exchange purchases aren't tracked by the federal government, those customers are part of the same risk pool as those who used the marketplaces, so their medical bills will be part of the equation used to set next year's prices.

In addition to the 8 million private health insurance enrollees from the exchanges, the department reported that 6.7 million individuals were determined eligible for Medicaid or the Children's Health Insurance Program, a tally that does not include anyone who signed up for those programs through state agencies. Since October, 4.8 million people in 47 states have joined these programs, according to a separate report issued by the Centers for Medicare and Medicaid Services Thursday. The Medicaid enrollment total is depressed because 24 states declined to accept federal funding to expand the program to more poor residents.

Health care spending appears to be on the rise after several years of historically low growth, provoking a minor freakout about whether the bad old days are back and whether Obamacare is ruining everything.

The latest data point being used to declare the Affordable Care Act a failure and get everyone all worked up is an advance estimate from the Department of Commerce's Bureau of Economic Analysis, which says health care spending increased 9.9 percent during the first quarter of this year after growing 5.6 percent in the last three months of 2013.

Well, pretty much anyone. And they did. Here's the Medicare and Medicaid actuaries in January, illustrating that spending would spike this year after several years of low growth, after which the rate of increase goes back down closer to historical levels.

Note: ACA refers to the Affordable Care Act. SGR refers to the system that determines how much Medicare pays physicians. The Office of the Actuary assumed Congress would prevent scheduled cuts to doctors' pay, including a 24.7 percent reduction set to take effect Jan. 1., which it did.Source: Health Affairs

The Congressional Budget Office expects federal health care spending to follow a similar trajectory, according to a report issued this month.

So what happened from January through March? The crazy-high prices Americans pay for health care didn't change much. Mainly, it seems that more people went to the doctor. Here's health care expert Larry Levitt, the senior vice president for special initiatives at the Henry J. Kaiser Family Foundation, to explain:

Use of health care increased at an annualized rate of 9.9% in the first quarter. Health care prices increased 0.6%.
http://t.co/AmxDGkRzr8

In other words, when people are broke or feel like they're broke, as many Americans did during the Great Recession and the lagging recovery, they spend less money on things they believe they can do without (or simply cannot afford). When people feel less broke, they start spending money on those things again. Likewise, people without health insurance don't get medical care they need, so when they get insurance, they might want to go see a medical professional.

Why should anyone even care? In one sense, greater spending on health care after the implementation of Obamacare suggests the law is succeeding at one of its goals: increasing access to medical care for the people who needed it. Extending coverage to tens of millions of people will increase health care spending by one-tenth of one percentage point each year over a decade, the Medicare and Medicaid actuaries projected in 2012.

But as with anything else, spending more money on health care means we have less money to spend on other things, and that applies to households, businesses and the government (which pays the bills for tens of millions of people on Medicare, Medicaid, subsidized private insurance and other programs).

Over the last several decades, health care has eaten up a greater share of our gross domestic product.

That suddenly changed from 2010 through 2012, when national health spending increased at a slower rate than the economy for the first time since 1997. However, no one expected that slow-down to last. Overall spending and health care's share of GDP was expected to tick back up. Here's another illustration from the federal actuaries.

These are all just projections and estimates, so reality could turn out to be very different, in either direction. Adding millions of people to the coverage rolls via private insurance or Medicaid, as the ACA appears to be doing, could boost spending by more than expected. Or the law's cost-saving mechanisms, which range from raw cuts to Medicare fees for health care providers to experiments designed to link payments to better-quality health care, could be more effective than expected.

Because everything with the words "health care" in it have been intensely politicized since 2009 when Congress started writing what eventually became the Affordable Care Act, every number that comes out has a tendency to be overanalyzed, and people on the left and the right have a tendency to draw grand conclusions from what can be pretty meager, preliminary information.

Case in point: Obama himself. The White House has been promoting analyses, both its own and from outsiders, that gave more credit to Obamacare for the recent slowdown in health care spending than the Medicare and Medicaid actuaries or lots of other experts. Now that the trend may be reversing, it's giving critics of the law an opportunity to say, "I told you so!"

It's going to be long time before anyone gets to say that and be sure they're right.

The top reason uninsured people didn't enroll in coverage under Obamacare this year is they still don't feel like they can afford health insurance, according to a new survey.

The findings in a report published by the Henry J. Kaiser Family Foundation Tuesday highlight the affordability gap facing some U.S. households, especially those with incomes near or above the income cutoff for tax credits that reduce premiums, or those who simply don't believe health insurance is a good value.

Thirty-six percent of people without health coverage reported they looked for health insurance during the enrollment period that nominally ended March 31, but found the available plans too expensive, according to the Kaiser Family Foundation survey. Just 7 percent said they preferred to pay a tax penalty under the law's individual mandate, rather than purchase an insurance policy. Others said they believed the mandate doesn't apply to them, didn't know about the mandate, or tried and failed to enroll.

Health insurance remains a costly product and the Affordable Care Act targets its financial assistance to low-income families. Tax credits to defray the cost of coverage aren't available to households that earn more than 400 percent of the federal poverty level, which is $45,960 for a single person. The law also provides subsidies to reduce out-of-pocket costs for those who earn up to 250 percent of poverty, or $28,725 for an individual.

The tax credits provided under the Affordable Care Act are pegged to the price of the second-cheapest "silver" level plan in a person's geographical area, and to household income. The subsidy gets smaller as income increases, so people who earn near 400 percent of poverty receive relatively little help paying for their coverage, and those who make just a little more pay full price.

The average national price for one of these benchmark silver plans is $808 a month for a household of two 40-year-olds with two minor children that earns over 400 percent of poverty, which is $94,200 for a family of four, according to a calculator on the Kaiser Family Foundation website. The same family making exactly 400 percent of poverty would be eligible for a tax credit worth $63 a month.

The vast majority of those enrolling in private insurance under Obamacare are getting help paying for their coverage. As of March 1, 83 percent of enrollees received tax credits for premiums, according to the Department of Health and Human Services.

The Kaiser Family Foundation report includes quotations from some of those surveyed that illustrate the point of view that health insurance is too costly. "What's out there now is just unaffordable," one respondent said. "Because I think food on the table is more important," wrote another. Coloring those views may be a general lack of awareness about the availability of the tax credits, previous surveys have shown.

Although not addressed in the Kaiser Family Foundation poll, the largest affordability gap in health coverage is found in 24 states that didn't adopt the Affordable Care Act's expansion of Medicaid to more poor people after the Supreme Court made it optional for states. Those earning up to 133 percent of poverty, or $15,282 for a single person, were supposed to have access to Medicaid, while tax credits are reserved for those who earn at least poverty wages, which amounts to $11,490 for an individual. That means the poorest residents of those 24 states aren't eligible for any help, so millions are expected to remain uninsured.

The Kaiser Foundation Family poll also shows a majority of Americans continue to disapprove of the Affordable Care Act, with 46 percent having an unfavorable view, compared with 38 percent holding a favorable opinion. These attitudes are closely tied to partisan affiliation, with Republicans being much more likely to disapprove and Democrats more likely to approve. A majority, however, wants Congress to improve the law, compared with more than one-third who would prefer it to be repealed and replaced with an alternative.

Despite President Barack Obama trumpeting the news this month that private insurance enrollments via the Obamacare exchanges have exceeded 8 million -- or 1 million more than the highest projection from the Congressional Budget Office -- the public doesn't see it that way. Even though more than 40 percent were aware that signups had topped 8 million, nearly six out of 10 said enrollment came in below the federal government's expectation.

In a remarkable rebound from the botched rollout of Obamacare, 8 million people have signed up for private health insurance via the exchanges created by the Affordable Care Act since October, President Barack Obama announced during a press briefing at the White House Thursday.

The official six-month enrollment period ended March 31, but the federal government and most states accommodated people trying to complete applications in April amid a last-minute surge for subsidized private coverage and Medicaid benefits.

"This law is working," Obama said. "This law won't solve all the problems in our health care system. We know we've got more work to do, but we now know for a fact that repealing the Affordable Care Act would increase the deficit, raise premiums for millions of Americans, and take insurance away from millions more."

Obama urged Republicans, who remain almost universally opposed to the health care law, to move on. "I find it strange that the Republican position on this law is still stuck in the same place that is has always been. They still can't bring themselves to admit that the Affordable Care Act is working," he said.

With the congressional GOP continuing its nationwide anti-Obamacare campaign heading into this fall's congressional elections, Obama's exhortations are in vain. “The president may want to silence any further debate about Obamacare, but in doing so he betrays a lack of confidence in his own policies and scant regard for those most affected by the law,” Senate Minority Leader Mitch McConnell (R-Ky.) said in a written statement.

Nevertheless, the inaugural Obamacare sign-up period managed to exceed expectations in the end, despite the disastrous rollout of HealthCare.gov and troubles with state-run exchanges in Oregon, Maryland and elsewhere. The Congressional Budget Office originally predicted that 7 million people would enroll in private coverage via the exchanges, and later downgraded it to 6 million to reflect the troubled enrollment websites.

The share of young adults who signed up over the six-plus months of enrollment represents an increase from the first half of the sign-up period, when less than one-fourth of private plan customers were younger than 35. The White House originally hoped that around 40 percent of private insurance customers would be younger, and presumably healthier. The proportion of younger customers who signed up this year is nearly identical to the first year of Massachusetts' health care reform program in 2007, which served as a model for the Affordable Care Act.

The ratio of young to old -- being used as an imperfect proxy for the ratio of sick to healthy -- will help determine premiums for plans sold on the exchanges next year. Although health insurance companies like WellPoint already are speculating about rate hikes that exceed 10 percent, price increases on that scale may not be in the offing, and other insurers are more bullish on Obamacare.

A fellow at the Society of Actuaries who analyzes insurance, Dave Axene, predicted to USA Today that average premiums will increase 6 percent to 8.5 percent next year, compared to 7 percent to 10 percent in previous years. Rate increases will vary by state and locality, as well.

The Obama administration hasn't yet released a breakdown of the enrollment figures that would allow for a full analysis of the first year of sign-ups through the exchange marketplaces.

The latest numbers also don't fully account for the effects of the Affordable Care Act's expansion of Medicaid to more low-income people, which 26 states and the District of Columbia adopted. Between October and February, total enrollment in those programs increased by 3 million people, according to the White House. The number may increase, however, as federal and state authorities sort through incomplete and stalled enrollments in these programs.

Moreover, crucial information remains unavailable, such as what proportion of customers secured their coverage by paying premiums to their health insurance providers, and how many of the private plan and Medicaid enrollees previously were uninsured.

Polling, estimates from outside groups, and leading indicators from sources beyond the Obama administration hint at the answers to some of these vital questions.

Survey data from Gallup and others indicates the share of Americans without health insurance has declined since the exchanges opened for business in October. According to Gallup, the uninsured rate went down from 18 percent in the fourth quarter of last year to 15.6 percent in the first three months of 2014. The rate declined further in states that adopted the Medicaid expansion, created their own health insurance exchanges, or both, Gallup reported.

The Congressional Budget Office expects the number of uninsured to decline by 12 million during 2014, according to a report issued this week. The CBO maintains that 6 million, not 8 million, people will secure private coverage via a health insurance exchange, largely because some customers won't pay their first premium or will let coverage lapse during the year, and because some will cycle out of the exchanges into other forms of insurance. The CBO also reduced its estimates for the cost of the Affordable Care Act.

Most, but not all, of those who enrolled using a health insurance exchange seem to have paid premiums, with estimates cited by former Health and Human Services Secretary Kathleen Sebelius, health insurance companies and some state officials at 80 percent and higher. That share may rise in the coming weeks as bills become due for those who signed up near or after the March 31 deadline for coverage that begins May 1.

The enrollment numbers will continue to be fluid throughout the year. People who experience "qualifying life events," such as getting married or moving to a new state, can shop for health insurance on the exchanges year-round, and enrollment in Medicaid and the Children's Health Insurance Program can be done at any time. The next open enrollment period begins Nov. 15, 2014, and ends Feb. 15, 2015.

CORRECTION: An earlier version of this article incorrectly attributed a projection about future health insurance premium increases to the Society of Actuaries. The analysis actually from one fellow at the society, Dave Axene.

As anyone who's ever paid a health insurance premium or a hospital bill knows, medical care is expensive. What Americans may not know is that residents of other countries don't pay nearly as much for the same things.

The latest data from the International Federation of Health Plans, an industry group representing health insurers from 28 countries including the United States, once again illustrates that American patients pay the highest prices in the world for a variety of prescription drugs and common procedures like childbirth and hospital stays.

To illustrate just how much more Americans pay for health care, the International Federation of Health Plans compared the prices for common medicines and services around the world in a report released on Thursday.

A prescription for Nexium, a popular remedy for acid reflux disease and other stomach ailments, costs $215 on average in the U.S., which is more than 3.5 times the cost in Switzerland, the second-most-expensive nation for Nexium prescriptions, and almost 10 times more than what Dutch people pay.

Prescription drugs are particularly expensive in the U.S. relative to elsewhere in large part because most other countries set prices for medicines through their universal health care programs, which the U.S. doesn't have. This can hit hardest for people, even those with health insurance, when they need the latest medicines to treat serious diseases.

Look at the price differences in the U.S. for these big-ticket prescription drugs, which are about twice as expensive in America as in the next-highest country and much more so than in the lowest-cost nations.

Sticker shock isn't just due at the pharmacy counter. U.S. hospitals, which took in the largest share of the $2.79 trillion Americans spent on health care in 2012, also charge more for many procedures than hospitals overseas, the report shows. The average daily cost of just being in a hospital is almost twice as expensive in the United States as it is in New Zealand, and almost 10 times as costly as stay in a Spanish hospital.

Likewise, the average price for heart bypass surgery in the U.S. is quite a bit higher than what the rest of the world pays, especially people in the Netherlands, who get off comparatively cheaply.

Being born in the United States has loads of advantages, but the cost of doing so isn't one of them, the report shows. A normal delivery is more expensive in the U.S. than in any of the other countries studied, and a Cesarean section is even costlier.

Read the entire International Federation of Health Plans report below:

So is Obamacare a success? Has President Barack Obama's signature health reform law revolutionized our broken health care system?

More than 7 million people used the Affordable Care Act's health insurance exchanges to buy private coverage through Monday, the end of the first sign-up period. Certainly the Obama administration is touting this as a huge victory.

"In these first six months, we've taken a big step forward," Obama said in the White House Rose Garden Tuesday. "The Affordable Care Act hasn't completely fixed our long-broken health care system, but this law has made our health care system a lot better."

Yet, there's still much we don't know about what the law has accomplished. Until we have answers to these five questions, it's still early to assess the full impact of Obamacare.

1. How many people really signed up for health insurance?

The 7.1 million figure the White House cited may be too low. The raw number doesn't include all of the most recent updates from 14 states and the District of Columbia, which have their own websites and saw a flurry of activity leading up to the open enrollment deadline. Nor does it include the applications still pending at the exchanges. Also missing: those who will sign up throughout the year when they become eligible because of a major life change, like marriage or moving to another state.

Confusingly, the 7 million number may also be too high: We don't know how many of those people took the crucial final step and actually paid their first month's insurance premium to lock in coverage. Based on anecdotal reports from individual insurance companies, Health and Human Services Secretary Kathleen Sebelius said 80 percent to 90 percent of consumers thus far had paid up. There also will surely be people who let their policies lapse during the rest of the year.

2. How many uninsured people gained coverage?

It's logical to assume that the Affordable Care Act reduced the ranks of the uninsured. There's a legal mandate to most people get covered or face tax penalties, and the law expands Medicaid and offers generous subsidies to low-income households. But logic isn't the same as data, and the Census survey many consider the gold standard won't even come out until September 2015.

Although the federal government can't or won't say how many enrollees from HealthCare.gov and state exchanges used to be uninsured, some states are reporting those figures. In Kentucky, 270,000 of the 370,000 people who enrolled via Kynect, the state's exchange, were uninsured -- meaning 43 percent of the Kentuckians without coverage are now enrolled. Likewise, more 70 percent of the 865,000 enrollees on New York State of Health previously were uninsured.

And an unknown number of uninsured people bought private insurance outside the exchanges. From Jan. 1 to mid-March, for example, 51 percent of those buying unsubsidized coverage via online broker eHealth reported they were uninsured. In addition, as many as 3 million young adults are now covered because of the 2010 Obamacare rule letting them remain on their parents' plans until they turn 26, according to the Department of Health and Human Services.

But even these survey data are open to some degree of doubt. People transition on and off insurance for a variety of reasons that predate Obamacare, like getting or losing a job and its health benefits, so it's difficult to tease what's happening because of the law.

3. Did enough healthy, young people get private insurance to balance out the costs of sicker people?

As of March 1, about one-quarter of nationwide private insurance enrollees were between the ages of 18 and 34, according to the Department of Health and Human Services. This matters because if only those who are heavy users of health care get covered, their medical bills will drive up future premiums. The White House originally hoped that 40 percent of those who bought the insurance would be young people, using age as an imperfect proxy for health.

The final share may or may not tick up much higher than 25 percent, but several health insurance companies recently have said their new customers were trending younger near the end of the enrollment period. EHealth reported the share of customers aged 18-34 rose from 39 percent during the first half to 45 percent during the second half.

According to the March HHS report, 4.4 million people were deemed eligible for Medicaid or the Children's Health Insurance Program via the health insurance exchanges, including individuals who qualified because the law expanded Medicaid and those who were entitled under the old rules but weren't signed up. That figure doesn't count anyone who signed up for the programs directly through a state agency.

A February report from the Centers for Medicare and Medicaid Services revealing that state agencies deemed 8.9 million people eligible for these programs also is problematic. That figure includes a mix of people gaining access because of Obamacare, people who previously were eligible but not enrolled and people who are simply renewing their existing benefits.

Finally, Medicaid and CHIP enrollment are open year-round, so more people will sign up while others drop out over the remainder of 2014. Twenty-four states haven't adopted Obamacare's Medicaid expansion, however, which will suppress enrollment.

5. How much more is health insurance going to cost next year?

Health insurance companies like WellPoint already are making noises about "double digit" premium hikes for 2015. That reflects their concern that the new customers they gained via the exchanges are sicker than the customers they had last year, since the law now requires them to accept anyone regardless of pre-existing conditions.

That means insurance companies will base their rates on the medical expenses they incur in each geographic location, not nationwide. The proportion of private insurance exchange customers under 35 years old varies a lot from state to state, as does the health of those populations. So consumers in some regions may get hit with big rate hikes next year, while consumers in others may see much smaller increases, or even decreases.

The latest tweak to the Obamacare deadline came in handy Monday when HealthCare.gov buckled during the rush by millions to sign up for health insurance by the original midnight cutoff.

Americans seeking to obtain health coverage at the last minute, and avoid tax penalties for remaining uninsured, flooded exchange websites and telephone lines Monday, with a record 3 million visits to Healthcare.gov and 1 million phone calls as of 8 p.m., according to the Department of Health and Human Services.

Federal officials said last week that people who couldn't enroll because of problems with HealthCare.gov would have more time to sign up. Some state-run health insurance exchanges offered similar flexibility for people who started applications prior to the March 31 deadline.

"There will be an opportunity for those who have initiated the process but aren’t able to finish it by midnight tonight to ensure that they get signed up for health insurance," White House press secretary Jay Carney said Monday. "If they start, they’ll be able to finish."

Although the President Barack Obama's administration and authorities in states such as California and Connecticut didn't technically extend the deadline for the end of the six-month sign-up period for private insurance via the exchanges, would-be enrollees snarled by technical problems can continue to enroll over the coming weeks, the administration said Wednesday.

Glitches on Monday were a far cry from the disaster that occured from when HealthCare.gov launched Oct. 1 through late November, and multiple readers told The Huffington Post that they'd successfully signed up. Others, however, were left without the coverage they sought.

Kelly O'Donnell, 35, of Greensboro, N.C., has been struggling to get an application filed for nearly a week and had no more luck Monday than before. When O'Donnell visited HealthCare.gov Monday, she was greeted by the virtual waiting room and opted to enter her email address to get notified when the website was ready to take on more users. But when the message arrived, the website still didn't work.

"I have used three different browsers and every time I am able to login but it takes me to a blank page," O'Donnell wrote in an email to HuffPost. Initially, O'Donnell worried she'd be subject to tax penalties for violating the Affordable Care Act's individual mandate that most Americans obtain health coverage, but now will give it another shot after the deadline.

"We're trying to start a family this year, so I definitely need health insurance," O'Donnell said by telephone.

In spite of the problems, others reported the website and enrollment process functioned smoothly.

Oklahoma City resident Louis Dollarhide, 62, spent 45 minutes on HealthCare.gov Monday morning and encountered no difficulties, he told HuffPost in a telephone interview. "It just clicks right through. I thought it was very straightforward, and I'm not a tech geek at all," he said.

Dollarhide has been uninsured since his previous employer closed four years ago. Now self-employed, he has been unable to afford new coverage because he has a condition called hereditary hemochromatosis that causes high levels of iron in the blood. "It's very easy to manage but it freaks these insurance companies out."

"I had a pre-existing condition, and so when I would get quotes for insurance, it was just astronomical. And I've always been in good health, even though I have this strange deal. It never causes any problems," Dollarhide said. An insurer once quoted him a $800 monthly premium, which was more than he could pay, he said. Health insurance companies can neither turn down people with pre-existing conditions nor charge them higher rates than healthy people under the Affordable Care Act.

Using HealthCare.gov, Dollarhide signed up for a "silver" plan, the second-lowest level of coverage available on the exchanges, for $289 a month, including tax credits that reduced his costs. Asked why he waited until the last day of the enrollment period to shop, Dollarhide replied: "Laziness and procrastination."

On the last day to sign up for Obamacare, evidence appears to be mounting that what started as a disaster may turn out a success.

Monday is the deadline to enroll in health insurance for 2014 via the health insurance exchanges created by President Barack Obama's Affordable Care Act, and it's clear that many waited until the last minute. The looming deadline and fear of the penalty for not getting covered has driven millions of people to the exchange websites, enrollment events and health insurance companies over the past few days.

"It's kind of the lead-up to Christmas right now, and all the last-minute shoppers are out," said Brian Lobley, senior vice president for marketing and consumer business at Independence Blue Cross in Philadelphia.

The company, which serves the city and its surrounding suburbs, signed up 28,000 customers in less than three weeks in March. It signed up 90,000 in the five months prior.

Edward Patton, 43, became one of those last-minute sign-ups Saturday afternoon. Patton, who works at a gas station, stumbled onto an enrollment event at a ShopRite grocery store near his home in Philadelphia.

"I just came to pick up a couple things," said Patton, who has never had health coverage before. He also picked up a "silver" level health insurance plan, the second-lowest level of coverage available on the exchanges, for $77.49 a month, including tax credits, which was far less than he expected to pay, he said. "This is good, just in case, because I barely get sick," he said.

"We're definitely seeing some younger consumers, as our average age of an applicant is going down," said Kurt Kossen, the vice president for retail marketing at Chicago-based Health Care Service Corp., which operates Blue Cross and Blue Shield companies in Illinois, Montana, New Mexico, Oklahoma and Texas. Online insurance broker eHealth reported a similar trend last week.

Insurance agents working for Independence Blue Cross assist customers signing up for health coverage at the company's Philadelphia headquarters Saturday.

Not everyone is so pleased with their new health plans. Households with incomes above four times the poverty limit, or about $95,400 for a family of four, don't qualify for financial assistance and can face hundreds of dollars in premiums every month for even basic coverage. And many people who previously purchased their own coverage directly from insurance companies saw their policies canceled last year because they didn't meet ACA standards, and had to replace them with plans that are often costlier because the mandated benefits are more generous.

The vulnerability of Obama's signature domestic policy achievement was evident during the early hours of Monday morning, when HealthCare.gov went down due to what the White House described as a software error not related to traffic on the website. The outage echoed the technical failures that marred the debut of the health insurance exchanges on Oct. 1 and hampered the first two months of the six-month enrollment period.

HealthCare.gov also drew record demand Monday when 1.2 million users visited the website by noon Eastern Time. First-time users of the website weren't able to create accounts for about an hour Monday afternoon and administrators twice activated the site's "virtual waiting room" when the number of people trying to log in surpassed its capacity, which is estimated at 100,000 users at once. State-run exchange websites in places like California and Maryland also experienced some difficulties. Telephone call centers for the exchanges were swamped by consumers seeking help, as well.

Although Monday is the nominal deadline for anyone who doesn't have health coverage to get insured this year, enrollments will continue through the coming weeks, since the Obama administration and most state-run health insurance exchanges are leaving the systems open for those who already started their applications but have not completed them by the end of the day.

Those who don't get health benefits from their jobs or through a government program won't be able to purchase private health insurance until the next open enrollment period begins Nov. 15 for policies that will take effect on Jan. 1, 2015.

Most people who fail to enroll in coverage for this year will face tax penalties under the ACA's individual mandate. There are a slew of exemptions from the mandate, however, and the health insurance exchanges will remain open for people who experience "qualifying life events," such as moving to a new state or losing their current health insurance plan. In addition, individuals eligible for Medicaid and the Children's Health Insurance Program can enroll year-round.

The process of preparing for the 2015 enrollment period will start almost immediately after the inaugural sign-up period ends, as health insurance companies must begin making projections about how much their new customers will cost them, and therefore how much to raise rates for next year. The federal government and states like Oregon and Maryland, which faced major technical problems, also must decide how to improve their performance so that next year's enrollment period goes more smoothly than this year's.

This post has been updated with information on traffic to Healthcare.gov on Monday afternoon.

The big Obamacare deadline looming on March 31 isn't just the last chance for most Americans to buy health insurance this year. It's also the last chance to avoid paying penalties under the Affordable Care Act's dreaded "individual mandate."

The individual mandate is one of the best-known but least-understood parts of President Barack Obama's signature health-care reform law. Here's how the mandate works, how much it costs to ignore the rule, and how you may be able to get out of it.

Who must have health insurance under Obamacare?

Practically everybody. But most Americans won't have to do anything on March 31. That's because about 80 percent of Americans already have health coverage -- through their jobs, a government program like Medicare or Medicaid, or directly from an insurance company. The small percentage of Americans who aren't insured risk having to pay a penalty under Obamacare. The complicated official name for this is the "individual shared responsibility payment." The IRS has more information, in case you thirst for still more complicated official language.

Who is exempt?

Many people are exempt from the mandate. Undocumented immigrants don't have to comply because they're not even allowed to use Obamacare's new insurance exchanges to buy coverage. Many Native Americans also don't have to comply, nor do those whose religious beliefs reject health insurance, people who don't make enough money to file federal income taxes, and people who can't find a health plan that costs less than 8 percent of their incomes. There's a full list here.

There are 14 different categories of hardship exemption, including things like being homeless, experiencing a death in the family, and filing for bankruptcy. And the administration is letting anyone whose old insurance policy was canceled because it didn't meet Obamacare standards apply for an exemption. The vaguest exemption, and therefore potentially the most useful to people who don't want to get health coverage, is described as: "You experienced another hardship in obtaining health insurance." And for some of these 14 reasons, you're not even required to show documentation of your hardship.

What's the penalty for not having health insurance?

People who go without coverage for more than three months this year will owe the IRS money for each additional month they are uninsured when they file their federal income taxes next year. The minimum penalty is $95 for each adult in a household and $47.50 for each child younger than 18 years old, capped at $285 no matter how large a family is. There's also some wiggle room regarding the three-month grace period: Anyone who enrolls by the end of this month won't owe a penalty even though their benefits may not kick until May 1.

Most taxpayers subject to the penalty will owe more than that, though. Under the law, the amount is the higher of $95 or 1 percent of household income minus the first $10,150 for a single person or $20,300 for a married couple filing jointly. So a married couple with two minor children and $50,000 in taxable income would owe $297, according to a calculator created by the Tax Policy Center at the Brookings Institution.

But there's a limit to how much anyone would ever pay. The penalty is capped at the national average annual price for a "bronze" health insurance plan on the Obamacare exchanges, the lowest-level plan available to everyone. The IRS hasn't calculated what that amount is yet, but the Tax Policy Center estimates that it's $3,600 for a single person and $11,000 for a family of four.

The penalties start getting bigger next year and will be $695 or 2.5 percent of income by 2016. So being uninsured when you can afford coverage -- according to Obamacare, anyway -- will get expensive. While it's cheaper than health insurance, you don't get anything in return and are still responsible for paying your own medical bills.

How is the individual mandate enforced?

In a word? Lightly. The ACA doesn't let the IRS come after you if you don't pay the penalty. Failing to pay isn't a crime. The government can't garnish your wages or put liens on your property to collect the money. Basically, the only way the IRS can get the dough against your will is to deduct it from your tax refund.

Without some way to push healthy people into the insurance market, the fear is that it'll fall apart. Mostly sick people would get insurance, which would drive up prices, which would lead to healthier people deciding not to buy any, which would force insurers to raise rates to cover their expenses, which would lead to even more healthy people opting out. That cycle is called a "death spiral" in insurancespeak.

That Matt Drudge, proprietor of The Drudge Report, is a lusty hater of Obamacare isn't a revelation. And the mercurial man behind the mammoth aggregator of right-leaning news has already declared he will go without health insurance for the rest of his life just to prove a point of some kind.

Even knowing all that, this tweet from Drudge on Friday was a little head-scratching:

Just paid the Obamacare penalty for not 'getting covered'... I'M CALLING IT A LIBERTY TAX!

Liberty tax! The whole thing is weird, considering that the tax penalty that adds bite to the the "individual mandate" -- the Affordable Care Act's diktat that most Americans have some form of health coverage -- isn't even due until more than a year from now, when people file their 2014 federal income-tax returns.

The White House jumped right on Drudge, in the form of a tweet from spokesman Jesse Lee.

Flat lie, no fee for previous year. Scary how much influence he once had. RT @DRUDGE: Just paid Obamacare penalty for not 'getting covered'

Briefly, here's how the individual mandate works: If you lack health insurance for more than three months in a year, you have to pay the IRS a penalty. (There are a whole slew of exemptions from this rule, however.) The penalty will be assessed on your tax return and taken out of whatever refund you're owed. Again, that won't happen until 2015 for people who aren't covered this year.

For 2014, the minimum penalty for an individual is $95 or 1 percent of your taxable income minus the first $10,150, whichever is higher. The penalty is capped at $3,600 for a single person this year, according to an estimate from the Tax Policy Center at the Brookings Institution. Families pay more depending on the number of people in the household. And the penalty is bigger in future years.

Of course, Drudge doesn't think the cost of the mandate penalty is any more real than President Barack Obama's birth certificate.

I've opted out of Obamacare for life. Not interested. Pay the tax. Monopoly money anyway...

"That's perplexing," said Brian Haile, the senior vice president for health-care policy at Jackson Hewitt Tax Service, a tax-preparation company. The IRS has no mechanism in place yet to even accept individual mandate penalties and hasn't even published the tables taxpayers will use to work out how much they owe. Plus, any money sent in can't be earmarked especially for that, he explained. The IRS didn't respond to a request for additional information about collecting mandate penalties. Drudge didn't respond to an email asking him to elaborate on his tweet.

"For whatever reason, Matt Drudge has decided to give the government an interest-free loan," Haile said.

Odd move for a small-government, anti-tax guy to make.

UPDATE: Drudge followed up on his earlier tweet and seems to confirm that he paid estimated taxes for the first quarter of this year on Friday. The mandate penalty nevertheless is separate from income taxes and isn't due until 2015.

Beneath all the partisan fury about Obamacare lies a surprisingly fundamental question: Just what exactly counts as health insurance?

A recent ad produced by an anti-Obamacare organization illustrates the issue. The Americans for Prosperity video features a Tennessee woman named Emilie Lamb whose monthly health insurance premium under Obamacare rose to $373 from $52.

Lamb, a 40-year-old accountant from Lawrenceburg who suffers from the chronic, incurable auto-immune disease lupus, is unhappy about the price hike. "I thought that Obamacare was going to be a good thing. Instead of helping, Obamacare has made my life almost impossible," she says in the Americans for Prosperity video.

If real health insurance were available for $52 a month, that's what everyone would have. BlueCross BlueShield of Tennessee, which administered Lamb's policy, didn't even call it "insurance," instead describing it as a "limited-benefit plan," the pro-Obamacare group Families USA noted in a 2009 report critical of CoverTN.

Lamb's new insurance, a top-notch "platinum" plan from the health insurance exchange, offers unlimited annual coverage, has no deductible, limits out-of-pocket expenses to $1,500 a year and comes with a rich benefits package as mandated by the Affordable Care Act. Lamb qualified for a tax credit that reduces her premiums by about $15 a month.

Her old plan is now illegal under Obamacare and is off the market. Much in the way that it's no longer legal to buy a car with no seat belts, it's no longer possible to buy health insurance that doesn't provide basic access to health care services and a high level of security against medical debt. Likewise, most states require a car owner to carry a minimum level of liability coverage -- not for the sake of that driver, but to protect anyone who might be harmed in a crash.

While consumers like Lamb are opposed to the changes forced by the law, larger societal and economic factors are at work. If patients are free to choose health policies that won't cover major medical expenses, that affects everyone else. Doctors and hospitals won't get paid, and those costs get spread throughout the health care system -- and passed on to taxpayers, who pick up a share of the cost of unpaid hospital bills every year through funding streams built into Medicare and Medicaid.

But this is a complex, difficult reality of the health care system that's not easy to simplify for a 60-second political advertisement set to sad music, and not as compelling as the personal story of a sick woman with limited means who's angry about changes she can't control.

Another person in Lamb's position could reasonably come to the opposite conclusion: that the Affordable Care Act's guarantee of coverage for people with pre-existing conditions, its comprehensive benefits package and the financial assistance it provides are tailor-made for a low- to middle-income person with a chronic medical condition like lupus. Under the old rules, a lupus patient could have been turned down for coverage or kicked off their plans when they got sick, and could have been charged higher prices than a healthier person.

It's worth noting that Lamb opted for a high-value and higher-cost platinum plan, instead of a cheaper bronze, silver or gold plan. She did so because a patient with ongoing health needs can save money by spending more on premiums and less on out-of-pocket costs, she told the Washington Post. A cheaper premium might well result in higher annual costs when deductibles and co-payments are figured in.

By Lamb's estimate, her annual costs will be about $4,500 higher with her new coverage, although she originally wrote in the New York Post and told other news outlets that number was $6,000. Is it worth it? Not in her opinion.

But consider a hypothetical alternative situation in which CoverTN still existed and Lamb still had its benefits. Depending on the severity of the disease and therapies prescribed, the average annual cost of lupus treatments ranges from $13,735 to $62,651, according to the Lupus Foundation of America. A bad year could drive her medical bills above $25,000.

"I am sure that my health care needs will change over the years. I know that I am not getting any younger, and every day I feel the effects of lupus a little more," Lamb wrote to HuffPost. Her current symptoms include patchy skin, fatigue, chronic joint and muscle pain, and kidney infections and stones, she wrote.

Lamb isn't worried about excess costs, though. When she racked up a $125,000 in medical costs after a horseback riding accident in 2007, CoverTN wound up footing most of her bills and keeping her below the $25,000 cap. She speculates that her medical providers would be willing to slash her bills again or set up a payment plan.

Philanthropy from an insurance company and a hospital isn't something most Americans would expect to rely on, though.

Ask anyone whose medical bills are in the hands of a collections agency, or who had to file for bankruptcy. What if the insurer couldn't drive the price down or the hospital refused to accept less than it was owed? Odds are Lamb would be financially devastated by medical bills that she'd never be able pay off, leaving health care providers and taxpayers holding the bag.

SALISBURY, Md. -- If you're wondering why the Obama administration is still so far from its goal of enrolling 6 million Americans into Obamacare, look no further than Maryland's Lower Eastern Shore.

The area is home to Ocean City, a local beach getaway. But beyond the sand, the three counties that make up the Lower Eastern Shore -- Somerset, Wicomico and Worcester -- also are known as some of the poorest areas in Maryland, with high rates of poverty, unemployment and uninsurance. In 2011, about 20,000 of the counties' 178,000 residents lacked health insurance, according to the most recent census data. That 14 percent rate was the fourth-worst in Maryland that year, and above the 2011 statewide uninsurance rate of 12 percent.

It is now up to a team of just 15 county health workers to get those people covered under the Affordable Care Act, President Barack Obama's signature health care reform law.

Convincing this poor, Republican-leaning population -- the area elected the state's only GOP member of the House and voted for Mitt Romney in 2012 -- to sign up for health insurance under Obamacare is painstaking work done at the individual level. A health worker must sit down with someone and guide them through the process -- that is, if they can find the uninsured.

"The uninsured are really hard to pinpoint. I mean, they're working families and individuals, and we have so many people who are self-employed, under-employed, contractors, farmers, watermen, service-sector Ocean City resort employees, small-business employees," said Katherine Gunby, the coordinator for the outreach program here.

"It's just a matter of making it clear to them that most of them are eligible for some type of assistance, and this is how they can get help signing up," Gunby, a 30-year-old from Salisbury, said.

Gunby's small crew, which operates out of the Worcester County Health Department with state funds of about $1.2 million, is responsible for spreading the word about the availability of the Affordable Care Act's two main components: subsidized private health insurance and Medicaid, a health benefit that's been expanded to include more poor Americans in half of the states, including Maryland. They have a huge swath of the state to cover -- three counties spread across 1,100 square miles.

At the March 8 enrollment event, Gunby, her team of 10 Obamacare "connectors," and four health insurance brokers were joined by two information technology technicians from the state, who were on hand to deal with website issues. Carolyn Quattrocki, the interim director of Maryland's troubled exchange, also attended to oversee the event in person.

During the five-hour event, people streamed into the Wicomico Youth & Civic Center in Salisbury to sign up for health insurance. Some waited more than a half-hour to be seen and more than an hour to get through their applications, seeking help applying for private insurance or Medicaid.

Attendees interviewed by The Huffington Post left happy. Amanda Weaver, a 33-year-old self-employed wedding photographer from Salisbury, signed up her family for coverage that's cheaper and more comprehensive than the plan she gave up in November when she left Starbucks, where she worked for the health benefits, to focus on growing a business. Lamont Morton, a 27-year-old from Fruitland who'd been unemployed and uninsured for three years after being laid off by Coca-Cola, left the civic center enrolled in a Medicaid plan from a private insurer.

"We finally got a plan," said Sheila Fisher, a two-time cancer survivor from Westover who had been unable to afford health insurance before Obamacare's passage prohibited health insurers from charging astronomical rates to those with "pre-existing conditions." For $271 a month including tax credits that cut the cost, Sheila and her husband, Samuel, got a low-level "bronze" plan plus dental coverage. The couple had been uninsured for three years.

Samuel and Sheila Fisher of Westover, Md., enrolled in a health plan at a Lower Shore Health Insurance Assistance Program event in Salisbury, Md., on March 8.

"We've seen just what can happen when you run up hospital bills and you own property," said Samuel Fisher, who works three hours away in a Washington, D.C., restaurant. Medical debts left after the death of Shelia Fisher's mother last year have been an issue for their family, he said.

The Fishers tried to sign up online and over the phone, but Maryland Health Connection failed them, he said. Technical problems with their application kept them at the civic center for more than an hour and half.

As is well-known, technological glitches have hampered both HealthCare.gov, the online portal to the health care exchanges in 36 states, and state-run marketplaces in locations like Oregon, Hawaii and Massachusetts. As improvements have rolled out at the federal and state levels, enrollments on the exchanges have continued to mount, topping 4.2 million in February.

Now that the March 31 deadline for private insurance enrollment is nearing and workers are figuring out ways around glitches, the pace of enrollment seems to be speeding up, according to one Lower Shore Health Insurance Assistance Program worker.

"We've gotten very busy over the last couple of weeks or so, and we're kind of expecting things to stay strong up until the end," said Jalissa Worthy, 25, of Salisbury.

So-called connectors like Worthy travel the surrounding counties each day spreading the word about how to sign up for health coverage. The 15 workers on Gunby's team typically visit a total of 30 locations every day, she said. That includes many events held across the area every week at county health departments, libraries, pharmacies, religious institutions, community health centers and other gathering places.

Worthy grew up on the Lower Eastern Shore and understands that the need is great. "I remember as a kid, lots of family members and lots of people in my local community who did work out on the water or who did work in the crab houses and the seafood places. And over the years, those have kind of dwindled down to nothing," she said.

Lamont Morton, who signed up for insurance at the March event in Maryland.

Other local industries have also shed jobs over the last decade or two, said Sue Gray, the CEO of Three Lower Counties Community Services in Salisbury, which operates community health centers in the area. "I've lived here 30 years, and we lost a lot of industry. Since we moved here, we lost Campbell's Soup, we lost Crown Cork and Seal, we lost Wayne Pumps," said Gray, a nurse by training.

Poultry conglomerates like Perdue Farms and Tyson Foods still provide a lot of jobs in the area, but not enough to go around. When jobs go, often so does access to affordable health insurance.

Unemployment, poverty and a lack of insurance aren't the only reasons why many people in this area need assistance with their health care, Gray said. "We have, as you could imagine, a large amount of people with comorbid conditions, where they are diabetic, hypertensive, overweight, have cardiac diseases," she said.

Not that every eligible person on the Lower Eastern Shore is clamoring to enroll. The team has to overcome misconceptions -- like the idea that there aren't any options for insurance, just one big program called "Obamacare" that everyone must join, Worthy said.

And some people still don't feel like they can afford health insurance even with subsidies, especially those for whom work is unsteady and income hard to predict, Worthy said. Poor people are forced to concentrate on their immediate needs, so committing to a bill they're not sure they can pay every month isn't always the obvious choice, she said.

"They only thing you can do is present the benefits to people and really try to have an honest conversation with them," she said. "I just try to get them to think of the long-term consequences."